A nurse is assigned to administer oral medications to a client. Which action will the nurse do first if a client refuses to take prescribed oral medications?

Inform the client that the nurse will get reprimanded for not administering the medication

Document the client’s refusal on the medication administration record

Ask the client the reason for refusing the medication

Inform the client that refusal is not permitted and it is required that the client take the medication

Answer and Explanation

The Correct Answer is C

Choice A reason: Informing the client about potential nurse reprimands is coercive and inappropriate, as it prioritizes the nurse’s interests over patient autonomy. This approach fails to explore the client’s reasons for refusal, which may involve side effects or mistrust, and does not support therapeutic communication or ethical care.

Choice B reason: Documenting refusal is necessary but not the first action. Exploring the reason for refusal allows the nurse to address concerns, potentially resolving issues like misunderstanding or side effects. Documentation follows after attempts to understand and educate, ensuring a therapeutic approach before recording the refusal.

Choice C reason: Asking the reason for refusal respects autonomy and initiates therapeutic communication. It identifies barriers like side effect fears or lack of understanding, enabling education or alternative solutions. This approach aligns with patient-centered care, addressing underlying issues to promote adherence while respecting the client’s rights.

Choice D reason: Stating that refusal is not permitted is coercive and violates autonomy. Clients have the right to refuse medication unless under involuntary treatment orders. This approach damages trust, escalates resistance, and contradicts ethical principles, making it an inappropriate initial response to medication refusal.

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Correct Answer is D

Explanation

Choice A reason: The right to do no harm (nonmaleficence) is an ethical principle, not a specific client right. While premature restraints may cause harm, this option does not directly address the legal right violated, which is the use of least restrictive interventions, making it less precise.

Choice B reason: Informed consent involves agreeing to treatments, not the use of restraints, which is a safety intervention. While clients should be informed, premature restraint use violates the right to least restrictive care, not consent, as restraints are not typically consensual interventions.

Choice C reason: Confidential and respectful care relates to privacy and dignity, not the method of intervention. Premature restraints violate the principle of using less invasive options first, not confidentiality or respect, making this right irrelevant to the specific violation described in the scenario.

Choice D reason: The right to least restrictive treatment requires using non-invasive interventions (e.g., de-escalation) before restraints. Premature restraint use violates this right, as mental health laws mandate the least coercive measures to ensure safety, prioritizing patient autonomy and minimizing harm, making this the correct answer.

A. Defense mechanisms can create difficulty with relationships B. Defense mechanisms can lead to poor problem-solving skills C. Defense mechanisms can help a person to reduce anxiety D. Defense mechanisms can inhibit emotional growth

Correct Answer is C

Explanation

Choice A reason: Defense mechanisms, like denial or projection, can strain relationships by avoiding honest communication or projecting blame, disrupting trust and emotional connection. While they may temporarily reduce anxiety, they hinder interpersonal dynamics, making this a negative outcome rather than a positive one in therapeutic interactions.

Choice B reason: Defense mechanisms can impair problem-solving by avoiding reality (e.g., denial) or displacing emotions, preventing rational analysis of issues. This leads to maladaptive coping, which does not address underlying problems, making it a negative consequence rather than a positive outcome of using defense mechanisms in mental health contexts.

Choice C reason: Defense mechanisms, such as repression or rationalization, temporarily reduce anxiety by shielding the individual from overwhelming emotions or stressors. By mitigating psychological distress, they provide short-term emotional relief, allowing the person to function under stress, making this a positive outcome when used adaptively in mental health management.

Choice D reason: Defense mechanisms can inhibit emotional growth by preventing individuals from confronting and processing emotions, leading to unresolved issues. Overreliance on mechanisms like avoidance stalls emotional development, hindering self-awareness and coping skills, making this a negative outcome rather than a positive benefit of defense mechanisms.

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A nurse is assigned to administer oral medications to a client. Which action will the nurse do first if a client refuses to take prescribed oral medications?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client feels that the client’s rights have been violated. Placing a client in restraints before using other methods of intervention violates which of the client’s rights?

Correct Answer is D

Explanation

The client has used defensive communicating with the nurse today. Which can be a positive outcome from the use of defense mechanisms?

Correct Answer is C

Explanation

The client states, “I understand that in order to leave, I must sign a request to withdraw from treatment.” What is the client’s legal status?

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When is a nurse legally obligated to breach confidentiality?